Wellsprings of Hope Christian Counseling

Informed Consent Form

Biblical Basis ~ Wellsprings of Hope bases all counseling on Biblical principles rather than on secular philosophies.  Wellsprings of Hope (herein after referred to as WOH) believes that Scripture is necessary and sufficient to guide us and instruct us in all things pertaining to life and godliness (2 Peter 1:3-4).  WOH has a goal of helping you build a strong personal relationship with God the Father, through His Son, Jesus Christ, by means of the Holy Spirit, which ultimately is the best way WOH can help you.

Disclosure ~ WOH utilizes counselors who are not psychologists or licensed mental health professionals.  WOH cannot provide you with assistance in the treatment of certain mental, emotional, or behavioral problems.  If you believe that you require the assistance of a professional counseling service, or you are presently under the care of a psychologist, psychiatrist, or other licensed mental health professional, WOH encourages you to seek such help.  In such cases, WOH will nevertheless seek to encourage you and offer supplemental biblical counseling.

Confidentiality ~ Information disclosed during your Biblical Counseling will be held in strictest confidence.  However, under certain circumstances, California law may require WOH to report information revealed during counseling.  These situations include, but are not limited to, elder or child abuse or neglect, imminent danger of homicide or suicide, or a court-ordered subpoena.  In some instances, WOH may seek the advice or assistance of a pastor or another counselor when necessary for the purposes of treatment planning only and your name and circumstances will remain confidential. 

Agreement of Financial Responsibility ~ I (client) assume financial responsibility for all charges rendered for my care.  I agree to pay WOH/Holly Nelson a fee of $100 per 50-60 minutes session for individual counseling, unless other arrangements have been made in advance.  I understand that an appointment commits Holly Nelson’s time to me, and unless 24-hours’ notice is provided, I am responsible for payment of any cancelled or missed appointments.

Resolution of Conflicts ~ Since WOH does not offer professional counseling, please read the following section carefully.  If you are in agreement, please print your name, sign the Release of Liability and return.  In order to offer you distinctively Bible-based counseling and to protect WOH from unwarranted legal action, we ask persons seeking counseling to agree to the following:

I understand that when the term “counseling” or “counselor” is used herein, or otherwise by Wellsprings of Hope, it does not refer to psychological, state licensed professional, psychiatric, or clinical medical advice.  I acknowledge that the method and process by which biblical counseling is provided by Wellsprings of Hope is different in many ways than a clinical or psychological counseling process.  I understand that any information disclosed during counseling will be held in strict confidence.  However, should the need arise to seek assistance; I hereby give permission for my information to be shared with another qualified person for the purpose of furthering the treatment goals.  Neither my name or identifying information will be communicated in such circumstances.

Release of Liability

In consideration that I am receiving biblical counseling and not professional, psychiatric, or clinical medical advice, I hereby release, acquit, and forever discharge Wellsprings of Hope, and Holly Nelson, and all participating counselors connected with Wellsprings of Hope, from any and all actions, courses of action, claims, demands, damages, costs, loss of service, expenses and compensation, on account of any and all known and unknown personal injuries, mental anguish or agitation, and damage claims to person or property resulting from or arising out of or related to counseling services provided by Wellsprings of Hope, Holly Nelson and/or its agents and representatives in any way affecting the undersigned.